Making a difference: Oklahoma nurse program recognized for assisting community

by Susan Trossman, RN

Kathy Bell was always interested in forensic nursing -- even before it had a name. But while working as a staff RN in the ICU starting in the mid-70s and later as a nursing supervisor, she freely admits that she did not have the expertise to determine what was potentially crime-solving evidence and what was not.

"In the critical care unit, I dealt with victims of violence and trauma regularly, and I'm sure I had evidence in my hands that I destroyed," said Bell, an Oklahoma Nurses Association member. "Many nurses have cut through bullet holes, given clothing back to the offender without realizing it or sealed belongings in a plastic bag where bacteria could destroy DNA evidence."

But Bell now is an expert in this growing specialty and the director of forensic nursing service for the Tulsa, OK, police department, where she oversees a nationally recognized program called the Tulsa Sexual Assault Nurse Examiner (SANE), as well as two other community programs aimed at children.

SANEs are nurses who have completed coursework in forensic nursing and work with victims of sexual assault. Like forensic nurses who focus on other populations, SANEs combine their nursing expertise with the sensitive collection and documentation of evidence for public or legal proceedings. There are more than 800 SANE programs throughout the United States, but most are not operated out of the police department like the one in Tulsa County, according to Bell.

Bell's connection with the Tulsa SANE program began when the program began -- in 1991. At the time, she was one of the nursing administrators at Hillcrest Medical Center, where victims were brought for treatment and the evidence-gathering exam. She immediately became the hospital's liaison to the program, a role that involved reviewing treatment records and making sure the facility was adequately meeting the needs of victims. Three years later, she joined the Tulsa SANE program as its coordinator.

Since 1991, nurse examiners with the program have seen about 2,300 adolescent and adult rape victims from Tulsa County and four bordering counties. Currently there are 15 nurse examiners who conduct these exams, and their work has not gone unrecognized. In 1994, Harvard University's John F. Kennedy's School of Government honored the program with an "Innovation in American Government Award." Just this year, Harvard again chose to recognize the Tulsa SANE program for its continued, noteworthy service over the past seven years.

Prior to the Tulsa SANE program's start-up, victims of sexual assault were taken to hospital ERs, where they might not have been triaged into the health care system as a high priority for care.

"Many sexual assault victims need immediate care, but not technical care," Bell said. "Some women in the past had tremendous waits. And some would just get up and walk away from the whole system."

Bell added that while ER nurses and physicians can handle the medical screening appropriately, many have had little training in forensic investigation.

Nurses trained in forensic nursing know how to spot evidence, such as looking at patterns on clothing, according to Bell.

"We look for little things -- hairs or fibers, gunshot powder -- and we know how to identify the potential cause of wounds," she said.

SANE-trained nurses also tend to be more sensitive when working with victims, who often are filled with guilt, shame and self-blame.

The Tulsa SANE program works like this: When a woman is assaulted, a police officer or a rape crisis line counselor will call the SANE department. The nurse examiner on-call will then meet the victim at Hillcrest Medical Center in a designated private room away from the ER. There, she will conduct the forensic exam and provide medical treatment, non-judgmental support and referrals for ongoing care. (Seriously injured victims would be treated first.)

The nurse examiner also will provide evidence to the police department and might later be called to testify in court. Bell said that the SANEs in her program come from a variety of settings -- public health, critical care and academia -- and each brings their special skills to the program, which has strengthened it.

Given the community's positive response to the adolescent and adult program, Bell added two programs targeting children. Since 1997, Tulsa nurse examiners have been responding to the roughly 60 acute sexual assaults of pre-pubescent children that occur each year. (Acute cases are those that occur within 72 hours of the assault.)

Again, Bell emphasized that SANEs are more tuned in to collecting evidence and eliciting information from young victims than other health care professionals who haven't gone through pediatric forensic training.

"Nurse examiners know the key to getting children to cooperate with the exam is to first alleviate their fears by developing a positive rapport with them," she said. "They have never had to hold a child down to conduct an exam."

The other newer Tulsa program began in 2001 and is called the "Drug-Endangered Children Program." Children seen in this program are those who have been rescued from homes where they've been exposed to methamphetamine labs. In this role, nurse examiners perform a physical assessment to see if the children have ingested any methamphetamine, collect evidence and prepare the children to go into protective custody.

In addition to overseeing the day-to-day operation of the programs and conducting forensic exams, Bell serves as president of the International Association of Forensic Nurses (IAFN). Over the past year, she has traveled around the country meeting with forensic nurses and encouraging other RNs to embrace this specialty.

"I can't think of a specialty area or setting where forensic nursing can't have an impact," she said. "School nurses, med-surg nurses, home health nurses, for example, all are likely to interact with abuse victims at some point."

Said Bell, "The nursing care you provide to individuals after they are assaulted can really make an impact on how they assimilate that incident for the rest of their lives."

For more information on forensic nursing, go to the IAFN Web site at www.forensicnurse.org.

Susan Trossman is the senior reporter for The American Nurse.